By Dr Dean Connolly
An ongoing body of work examining alcohol and other drug (substance) use by transgender (trans) people began with a systematic review which sought to report on the prevalence and correlates of substance use in this community. We systematically searched four databases with broad inclusion criteria. More than forty studies were included in the final synthesis which reported high and excess prevalence of substance use among trans people. Lending support to the gender minority stress model, we found several gender minority-related correlates of substance use by trans people reported throughout the literature, including transphobic discrimination, unemployment, sex work and gender dysphoria.
While these results are significant and likely clinically meaningful, the most important finding of the review related to sampling limitations and the associated poor generalisability of the existing research. Studies largely reported on convenience and respondent-driven samples of North American participants with multiple intersectional disadvantages e.g., minority ethnic trans women with a history of sex work or those experiencing current gender dysphoria. Consequently, less is known about the experience of trans women without these disadvantages, trans men and there are no studies reporting between group comparisons of substance use measures which included non-binary participants.
The Global Drug Survey (GDS) is the world’s largest annual, self-administered, multilingual online survey designed to monitor international patterns of substance use and related behaviour. A detailed account of GDS methodology can be found here. Collaboration with members of the GDS team of multidisciplinary experts provided a unique opportunity to build on the systematic review findings. GDS provides a large (~120,000 respondents/year) sample from >40 countries and adopts a two-stage approach to assessing gender that allows respondents to self-identify as trans and crucially allows for the identification of non-binary respondents.
By giving non-binary people a voice, GDS is able to report on their experiences of drug-related harms, together with other gender minority respondents or as an independent group. The GDS COVID-19 Special Edition used both approaches. It found that 35% of trans and non-binary respondents reported that they started drinking earlier in the day following the onset of the COVID-19-related social restrictions and that daily binge drinking (³5 drinks/occasion) was reported by twice as many trans and non-binary respondents than cis men or cis women. For the survey module exploring relationships and intimate partner abuse (IPA), non-binary participants were not considered alongside other gender minority respondents but were instead in a category where participants or their partners had to be non-binary for inclusion. Analysis with these groups found that non-binary participants or participants with non-binary partners were most likely to report both experiences and perpetration of IPA during the COVID-19-related social restrictions.
We have built on what’s found in each survey’s report with research papers seeking to answer specific questions. While several of these are under review or in development, we are able to report on two studies here. We used data from both GDS2018 and GDS2019 for a study which examined substance use help-seeking intentions among 185,055 (2,579 trans) respondents. We believe this is the largest sample of trans participants with cis comparators in the substance use literature. Perhaps unsurprisingly, we found that non-binary people were more likely than any other gender group to report a need for help to reduce their use of alcohol and cannabis. Trans women most frequently reported needing help to reduce use of illicit substances.
Using data from a sexual violence module in GDS2019, we compared experiences of “being taken advantage of sexually” while under the influence of substances between cis and trans respondents and subgroups of trans respondents (binary (trans men/women) vs non-binary; transmasculine1 vs transfeminine2). We found that trans respondents were more likely to report experiences of sexual violence than cis respondents. There were no significant differences in these experiences between trans subgroups in the last 12 months. However, non-binary and transmasculine respondents were significantly more likely than their respective comparators to report this violence more than 12 months preceding the survey.
To date, we have found that: a) the substance use literature largely excludes non-binary people; b) non-binary people appear to be more likely to report problematic substance use; c) non-binary people may require more support with reducing substance use than people of other genders; d) non-binary people may be at increased risk of experiencing sexual abuse when under the influence of substances, relative to cis and binary trans people. These findings are described with caution because of methodological limitations. GDS is a non-representative, predominantly Caucasian, Western European, and highly educated sample. The research is cross-sectional and the regression analyses in some papers are sub-optimally controlled because of the small trans sample and high non-response rates for demographic variables. Consequently, it is difficult to be confident about the nature of the relationship between these substance use and gender variables.
However, GDS’s purposive sampling technique and associated volunteer bias allow for the large cohort of trans respondents in our sample. Samples with so many trans (>1,500/year3) and non-binary (>1,000/year3) participants alongside >100,000 cis comparators are novel, add weight to our results and appear to be crucial in identifying disparities in substance use and associated harms among non-binary people.
We recommend the following:
- Use of a two-stage approach to measuring gender in surveys and by substance use disorder services to allow identification of trans and/or non-binary people
- Questions related to current/lived gender identity should include response options which reflect the diversity of terms used to describe gender identity, with a free-text option to maximise inclusivity. People should be allowed to choose more than one response option
- Clinicians should be trained in trans-affirmative language and practice
- Development and implementation of specialist substance use disorder interventions for trans and/or non-binary people
- A greater focus on trans men and non-binary people in substance use research in view of the disproportionate investigation of trans women to date
- A greater effort to include trans people in sexualised drug use research
- Support for countries outside North America to replicate and build on existing research largely conducted in the United States. We have designed a mixed-methods study of UK-based trans and/or non-binary people who use substances to begin to address this
- The above systematic review should be updated regularly to reflect the rapid development of this growing area of research.
1 Transmasculine describes individuals who were assigned female at birth but identify more with masculinity.
2 Transfeminine describes individuals who were assigned male at birth but identify more with femininity.
3 Refers to GDS 2018 and GDS 2019 survey years. Data was collected between 8th November and 30th December, 2017; and between 29th October and 30th December, 2018, respectively.
Dr Dean Connolly (he/they) is a London-based Foundation Doctor and Visiting Researcher at King’s College London. He has a special interest in health inequalities and is currently researching substance use and dependence within LGBT+ communities.